A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.
After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.
The triage nurse does a rapid assessment of the client.
1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.
Click to highlight the data that indicate the client is in need of immediate health interventions.
A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.
A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.
A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.
After having a few drinks at a local seafood restaurant, the client’s husband noticed his wife’s speech became difficult to understand.
1915: Client arrives via personal car to emergency department with facial drooping and garbled speech.
Correct Answer : A,B,C,E
Choice A rationale:
The client’s presentation of a noticeable facial droop and garbled speech are classic symptoms of a stroke. These symptoms indicate that the brain is not receiving enough oxygen, which can lead to permanent damage if not treated immediately. Therefore, this client requires immediate health interventions.
Choice B rationale:
This choice is identical to Choice A. The client’s noticeable facial droop and garbled speech are indicative of a stroke and require immediate attention.
Choice C rationale:
This choice is also identical to Choices A and B. The client’s symptoms are indicative of a stroke, which is a medical emergency that requires immediate intervention.
Choice D rationale:
While the change in the client’s speech after having a few drinks at a restaurant could be due to alcohol consumption, it could also be a symptom of a stroke, especially when combined with the facial droop. However, this choice does not directly indicate the need for immediate health interventions as it lacks the specificity of the symptoms compared to Choices A, B, and C.
Choice E rationale:
The time of arrival and mode of transportation do not directly indicate the need for immediate health interventions. However, the mention of facial drooping and garbled speech upon arrival at the emergency department reinforces the urgency of the situation, as these are classic symptoms of a stroke. In conclusion, Choices A, B, C, and E all highlight data that indicate the client is in need of immediate health interventions due to potential stroke symptoms. It’s important to note that strokes require immediate medical attention to minimize brain damage and potential complications. Normal ranges for lab parameters would not apply in this scenario as it’s based on clinical observations rather than laboratory findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Notify your healthcare provider if you start having abdominal pain.
Choice A rationale:
Exenatide does not act in the same way as insulin. Insulin directly lowers blood glucose levels by facilitating the uptake of glucose into cells, while exenatide is an incretin mimetic that enhances glucose-dependent insulin secretion and slows gastric emptying.
Choice B rationale:
Exenatide should be injected within 30 minutes before or after a meal, but this is not the most critical information for discharge instructions.
Choice C rationale:
There are precautions about taking exenatide with other medications, especially those that affect kidney function or interact with exenatide.
Choice D rationale:
Notifying the healthcare provider if abdominal pain starts is crucial because exenatide can cause side effects such as pancreatitis, which presents with severe abdominal pain. Early detection and intervention are essential for patient safety.
Correct Answer is D
Explanation
Choice A rationale:
Systemic autoimmune vasculopathy is not a typical underlying disease pathology associated with a waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice B rationale:
Autonomic neuropathy may manifest with a variety of symptoms, including autonomic dysregulation, but it is not a common underlying pathology leading to a waddling gait and frequent falls in a child. This choice is not relevant to the symptoms described.
Choice C rationale:
Impaired neuron function can result in various neurological symptoms, but it does not specifically explain the waddling gait and frequent falls in a 5-year-old child. This choice is not relevant to the symptoms described.
Choice D rationale:
Muscle fiber degeneration is the most appropriate explanation for the symptoms of a waddling gait and frequent falls in a 5-year-old child. These symptoms are indicative of a neuromuscular disorder known as Duchenne muscular dystrophy (DMD), which involves progressive muscle weakness and degeneration. DMD is characterized by the loss of muscle fibers and is a common cause of a waddling gait and falls in affected children. Therefore, choice D is the correct answer based on the understanding of the underlying disease pathology.
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